1. EN~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ On the Subject of Caring For and Caring About Patients C. A. Leftridge, Jr., MD Gainesville, Florida
Recognition of the growing familiarity on the part of physicians in approaching patients is presented with discussion of alternative approaches to establishing rapport and, at the same time, respecting the rights and preserving the dignity of the patient. Courtesy is a science of the highest importance. It is like grace and beauty in the body, which charm at first sight and lead on and friendto further intimacy ship. . . Michael de Montaigne.
During the long, and sometimes arduous, years of medical training, I have had some time to reflect on a subject that was never presented to me during any lecture series but, perhaps, in retrospect should have been. The title of this communication is somewhat misleading as the subject has not much to do with the caring for patients in a strict medical sense but has more to do with the caring about patients.
Caring About Patients I should like to preface the comments which are to follow by offering a short anecdote, and an even shorter statement of fact. Once, while a junior in medical school, I presented a patient to the late Dr. "Red" Brown of Meharry Medical College. I started with the usual opening gambit, "The patient is a 60-yearold female who presented, etc." Living in absolute fear of Dr. Brown (a fear which was absolutely baseless), I made sure that I included everything I could Requests for reprints should be addressed to Dr. C. A. Leftridge, Department of Radiology,
Shands Teaching Hospital, Gainesville, FL 32610.
in the history, physical, and diagnosis. Following what I felt was a fine workup and presentation, we continued discussing the case at the patient's bedside. As we moved out of the room, he called all of us aside and quite simply said that when one presents a patient, either at the bedside or even in the sterile confines of a lecture hall, one should remember that patients are people who have form, substance, and purpose in their lifetime, however long or short that lifetime may be. It is a travesty to reduce patients, particularly when presenting at the bedside, to the unfeeling and lowly stature of being simply males and females. He asked us to think how much more purposeful a patient would feel if he or she was presented as a 60-year-old schoolteacher, a retired gardener, lawyer, or housewife; one has but to look at the patient, he went on, and determine instantly what the patient's sex happens to be. If one is in a lecture hall and the patient is not present, the history provides ample time to place the pronouns he or she in the appropriate position to alert the listener as to the sex of the patient. With that, "professor's rounds" concluded. The subject never came up again. The simple statement of fact is that the opinions which follow are purely my own and are not stated as to right vs wrong, but represent alternatives to perhaps more conventional and established thought.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Insensitivity Toward Patients In the past few years, I have talked to numerous hospitalized patients and patients who have had occasion to visit the offices of private practitioners and/or clinics. Almost uniformly, they complain of an apparent insensitivity shown by physicians and paramedical personnel. One lady, who had a gynecologic problem, remarked that while a private patient in a teaching hospital, she was subjected to numerous examinations by housestaff to the point that she almost felt like she had been raped. She related that it was not the number of examinations which bothered her so much, but the apparent callous nature of the examiners who also took the liberty to call her "honey," "dear," and by her first name, Sadie. The latter bears special notation as many patients object to being called by their first names without first giving a physician license to do so. Many of us cannot deny what a shock it would be to say to a patient, "How are you today, Mary?" and have the patient reply in kind, "Oh, I feel pretty good, Richard." Another gentleman remembers being hospitalized for surgery and prior to surgery, he closed his hospital room door to have a "private conversation with God." Halfway through his "conversation" the door was abruptly pushed open and four young doctors descended upon him. "George," one young doctor said, "We want to feel your belly." Without waiting for the patient to make any type of answer, four pairs of hands in rapid sequence scoured his abdomen, discussed his problem and shuffled off to, no doubt, 351
repeat the same intrusion on another patient. The patient remembers having to realign his hospital gown which was left unceremoniously gathered up around his neck and choked back tears for having been treated "like a side of beef hanging in somebody's smokehouse." I can personally remember sitting in on a multidisciplinary conference and watching the face of an anxious patient who sat and listened to a cadre of physicians discuss the treatment approach to this woman who had carcinoma of the cervix. She sat quietly while all had their say and finally whispered in a crackling, almost inaudible voice, "Doesn't anybody want to hear what I have to say about what you plan to do with me?" In medical school we have lectures on everything from Apert syndrome to Zollinger-Ellison syndrome, but nowhere can I remember a single, solitary lecture devoted to the need to recognize the pride and dignity inherent in every patient and how to approach the patient to keep those two modalities intact.
Bedside Rounds Bedside rounds are, quite obviously, a necessary part of medical education. But just as importantly, bedside rounds present an excellent opportunity to teach aspiring young physicians to care about, as well as to care for patients. I was recently thrilled-I can think of no other word to convey my feeling-to read a short communication by Iversen and Clawson1 wherein bedside decorum for doctors was discussed. In the short but succinct article, they point out how patients can be examined at the bedside with feeling and respect. During my internship, when presenting a patient to an attending physician, I always went to the patient on the night before and asked if he/she would mind if several physicians stop by tomorrow to talk with them and perhaps examine them. With rare exceptions, each would say "yes." After gaining permission, when we visited the patient on rounds, I would enter the room first to be sure the patient was "presentable" (if a nurse was in attendance she entered before anyone else for the same reason). After ascertaining that the patient was "presentable," I would enter 352
and introduce the attending to the patient by simply stating, "Dr. Jones, this is Mr. Smith. Mr. Smith, this is Dr. Jones who is very interested in your hospitalization as are the other doctors in the room." Following the exchange of greetings, we would discuss the case at the bedside. At this point, I must state the obvious: all attention should be on the discussant; side conversation has no place at the bedside as it may upset the patient and is rude to all others in attendance. Following the case discussion, I would, almost without fail, try to remember to say two things to the patient, "Mr. Smith, do you have any questions you would like to ask us," and, "Thank you, Mr. Smith, for allowing us to see you this morning." Prior to leaving the patient's room, I thought it appropriate to let the patient know that I would check back with him to keep him apprised of our progress to date.
First Names With regard to first names, I firmly believe that their use is to be avoided until the patient offers you the right to use his or her first name. Somehow, the idea is that if the physician calls the patient by his or her first name or some "endearing term," rapport is instantly established. That may be quite true for some patients, but one cannot be sure of the desires of a particular patient. I feel it is far safer and, perhaps, even more prudent to assume that each patient prefers not to be addressed on a first name basis until "proved otherwise." Rapport can be established quite easily without the use of first names by simply showing the patient that you are prepared to spend as much time as needed to conduct a thorough history and physical and that you are in sympathy with this patient's straits.
Common Terms Another habit adopted by physicians is the use of, what I euphemistically shall call "common terms." For example, the term "belly" is often used when taking a history and conducting a physical examination. "Mrs. Green, how often does your belly hurt?" "Mr. Brown, how often do you have to get up from bed to pee?" These terms, I
believe, are base and objectionable and immediately suggest that the patient does not have a good command of the English language. I can remember once listening to a fellow intern jokingly relate to a group of us at lunch how he said to a patient, "Mr. Red, does eating fried foods make you puke?" The patient responded, "No, Doctor, I have neither felt nauseated, nor have I regurgitated while eating fried foods. " I do not particularly worry about using words that the patient may not understand as it seems easy enough to tell the patient that during your discussion with him, that if you use any unfamiliar terms, he or she should feel free to stop you so that you can explain the term to their satisfaction.
Listening The last point I should like to make is the absolute necessity of listening to patients. Dr. Matthew Walker, past Chairman of the Department of Surgery at Meharry Medical College, used to say, "If you young doctors would just be quiet and listen to patients, sometimes they will make the diagnosis for you." How right I have found him to be on more occasions than I care to remember. During a work-up, a block of time should be set aside for the patient to discuss his/her problem in any manner that he/she chooses, without interruption. Somewhere, a pearl may be given that might clinch the diagnosis. No, I do not have an anecdote for that but simply listening is worth trying if you have not already done so.
Conclusion In concluding, I have this recurring nightmare, that someday I shall become a patient and while lying in bed, four patients will barge in my room disguised as doctors and say, "Cliff, we want to feel your belly." I am not so sure I want that to happen to me or to you.
Literature Cited 1. Iversen LD, Clawson DK: Doctor and Patient. New Physician 26:59, 1977
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Recognition of the growing familiarity on the part of physicians in approaching patients is presented with discussion of alternative approaches to establishing rapport and, at the same time, respecting the rights and preserving the dignity of the patient. Courtesy is a science of the highest importance. It is like grace and beauty in the body, which charm at first sight and lead on and friendto further intimacy ship. . . Michael de Montaigne.
During the long, and sometimes arduous, years of medical training, I have had some time to reflect on a subject that was never presented to me during any lecture series but, perhaps, in retrospect should have been. The title of this communication is somewhat misleading as the subject has not much to do with the caring for patients in a strict medical sense but has more to do with the caring about patients.
Caring About Patients I should like to preface the comments which are to follow by offering a short anecdote, and an even shorter statement of fact. Once, while a junior in medical school, I presented a patient to the late Dr. "Red" Brown of Meharry Medical College. I started with the usual opening gambit, "The patient is a 60-yearold female who presented, etc." Living in absolute fear of Dr. Brown (a fear which was absolutely baseless), I made sure that I included everything I could Requests for reprints should be addressed to Dr. C. A. Leftridge, Department of Radiology,
Shands Teaching Hospital, Gainesville, FL 32610.
in the history, physical, and diagnosis. Following what I felt was a fine workup and presentation, we continued discussing the case at the patient's bedside. As we moved out of the room, he called all of us aside and quite simply said that when one presents a patient, either at the bedside or even in the sterile confines of a lecture hall, one should remember that patients are people who have form, substance, and purpose in their lifetime, however long or short that lifetime may be. It is a travesty to reduce patients, particularly when presenting at the bedside, to the unfeeling and lowly stature of being simply males and females. He asked us to think how much more purposeful a patient would feel if he or she was presented as a 60-year-old schoolteacher, a retired gardener, lawyer, or housewife; one has but to look at the patient, he went on, and determine instantly what the patient's sex happens to be. If one is in a lecture hall and the patient is not present, the history provides ample time to place the pronouns he or she in the appropriate position to alert the listener as to the sex of the patient. With that, "professor's rounds" concluded. The subject never came up again. The simple statement of fact is that the opinions which follow are purely my own and are not stated as to right vs wrong, but represent alternatives to perhaps more conventional and established thought.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
Insensitivity Toward Patients In the past few years, I have talked to numerous hospitalized patients and patients who have had occasion to visit the offices of private practitioners and/or clinics. Almost uniformly, they complain of an apparent insensitivity shown by physicians and paramedical personnel. One lady, who had a gynecologic problem, remarked that while a private patient in a teaching hospital, she was subjected to numerous examinations by housestaff to the point that she almost felt like she had been raped. She related that it was not the number of examinations which bothered her so much, but the apparent callous nature of the examiners who also took the liberty to call her "honey," "dear," and by her first name, Sadie. The latter bears special notation as many patients object to being called by their first names without first giving a physician license to do so. Many of us cannot deny what a shock it would be to say to a patient, "How are you today, Mary?" and have the patient reply in kind, "Oh, I feel pretty good, Richard." Another gentleman remembers being hospitalized for surgery and prior to surgery, he closed his hospital room door to have a "private conversation with God." Halfway through his "conversation" the door was abruptly pushed open and four young doctors descended upon him. "George," one young doctor said, "We want to feel your belly." Without waiting for the patient to make any type of answer, four pairs of hands in rapid sequence scoured his abdomen, discussed his problem and shuffled off to, no doubt, 351
repeat the same intrusion on another patient. The patient remembers having to realign his hospital gown which was left unceremoniously gathered up around his neck and choked back tears for having been treated "like a side of beef hanging in somebody's smokehouse." I can personally remember sitting in on a multidisciplinary conference and watching the face of an anxious patient who sat and listened to a cadre of physicians discuss the treatment approach to this woman who had carcinoma of the cervix. She sat quietly while all had their say and finally whispered in a crackling, almost inaudible voice, "Doesn't anybody want to hear what I have to say about what you plan to do with me?" In medical school we have lectures on everything from Apert syndrome to Zollinger-Ellison syndrome, but nowhere can I remember a single, solitary lecture devoted to the need to recognize the pride and dignity inherent in every patient and how to approach the patient to keep those two modalities intact.
Bedside Rounds Bedside rounds are, quite obviously, a necessary part of medical education. But just as importantly, bedside rounds present an excellent opportunity to teach aspiring young physicians to care about, as well as to care for patients. I was recently thrilled-I can think of no other word to convey my feeling-to read a short communication by Iversen and Clawson1 wherein bedside decorum for doctors was discussed. In the short but succinct article, they point out how patients can be examined at the bedside with feeling and respect. During my internship, when presenting a patient to an attending physician, I always went to the patient on the night before and asked if he/she would mind if several physicians stop by tomorrow to talk with them and perhaps examine them. With rare exceptions, each would say "yes." After gaining permission, when we visited the patient on rounds, I would enter the room first to be sure the patient was "presentable" (if a nurse was in attendance she entered before anyone else for the same reason). After ascertaining that the patient was "presentable," I would enter 352
and introduce the attending to the patient by simply stating, "Dr. Jones, this is Mr. Smith. Mr. Smith, this is Dr. Jones who is very interested in your hospitalization as are the other doctors in the room." Following the exchange of greetings, we would discuss the case at the bedside. At this point, I must state the obvious: all attention should be on the discussant; side conversation has no place at the bedside as it may upset the patient and is rude to all others in attendance. Following the case discussion, I would, almost without fail, try to remember to say two things to the patient, "Mr. Smith, do you have any questions you would like to ask us," and, "Thank you, Mr. Smith, for allowing us to see you this morning." Prior to leaving the patient's room, I thought it appropriate to let the patient know that I would check back with him to keep him apprised of our progress to date.
First Names With regard to first names, I firmly believe that their use is to be avoided until the patient offers you the right to use his or her first name. Somehow, the idea is that if the physician calls the patient by his or her first name or some "endearing term," rapport is instantly established. That may be quite true for some patients, but one cannot be sure of the desires of a particular patient. I feel it is far safer and, perhaps, even more prudent to assume that each patient prefers not to be addressed on a first name basis until "proved otherwise." Rapport can be established quite easily without the use of first names by simply showing the patient that you are prepared to spend as much time as needed to conduct a thorough history and physical and that you are in sympathy with this patient's straits.
Common Terms Another habit adopted by physicians is the use of, what I euphemistically shall call "common terms." For example, the term "belly" is often used when taking a history and conducting a physical examination. "Mrs. Green, how often does your belly hurt?" "Mr. Brown, how often do you have to get up from bed to pee?" These terms, I
believe, are base and objectionable and immediately suggest that the patient does not have a good command of the English language. I can remember once listening to a fellow intern jokingly relate to a group of us at lunch how he said to a patient, "Mr. Red, does eating fried foods make you puke?" The patient responded, "No, Doctor, I have neither felt nauseated, nor have I regurgitated while eating fried foods. " I do not particularly worry about using words that the patient may not understand as it seems easy enough to tell the patient that during your discussion with him, that if you use any unfamiliar terms, he or she should feel free to stop you so that you can explain the term to their satisfaction.
Listening The last point I should like to make is the absolute necessity of listening to patients. Dr. Matthew Walker, past Chairman of the Department of Surgery at Meharry Medical College, used to say, "If you young doctors would just be quiet and listen to patients, sometimes they will make the diagnosis for you." How right I have found him to be on more occasions than I care to remember. During a work-up, a block of time should be set aside for the patient to discuss his/her problem in any manner that he/she chooses, without interruption. Somewhere, a pearl may be given that might clinch the diagnosis. No, I do not have an anecdote for that but simply listening is worth trying if you have not already done so.
Conclusion In concluding, I have this recurring nightmare, that someday I shall become a patient and while lying in bed, four patients will barge in my room disguised as doctors and say, "Cliff, we want to feel your belly." I am not so sure I want that to happen to me or to you.
Literature Cited 1. Iversen LD, Clawson DK: Doctor and Patient. New Physician 26:59, 1977
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
